Above average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Surprise Valley Community Hospital D/p Snf during CMS and state inspections, most recent first.
Surveyors identified that the facility did not have an approved and implemented policy for end-of-life care. During an interview and record review, the Medical Records Manager acknowledged that a document titled “Comfort Care and End-of-Life” existed only in draft form and had not been approved as an official P&P. In a separate interview, the DON stated they were unaware of any prior end-of-life care policy. This resulted in the absence of a formal, implemented framework to guide staff in providing comfort and end-of-life care according to residents’ preferences and goals.
A resident with severe cognitive impairment alleged rough treatment during a shower, but the abuse allegation was not promptly reported by staff to the DON or to CDPH as required by facility policy. The incident was discussed among staff and residents for weeks before formal reporting occurred, resulting in delayed notification to authorities.
Surveyors identified numerous unsanitary conditions in the dietary department, including chipped paint, exposed wood, burnt-on food on kitchenware, ice build-up in the freezer, damaged ceilings and walls, and uncleanable surfaces throughout food prep, storage, and dishwashing areas. Staff confirmed these issues made proper cleaning impossible and acknowledged the potential for infection control problems, in violation of facility standards for food safety and sanitation.
Three residents did not have their care plans updated to reflect significant changes in condition, including a rash, skin breakdown, and initiation of comfort care. Documentation in clinical records and physician orders identified these changes, but the care plans were not revised accordingly, as confirmed by the DON.
The facility failed to submit the required PBJ staffing information to CMS. The FA, DON, HR, and AC were all unsure who was responsible for the submission, and no evidence was provided to show compliance.
The facility failed to implement a program to prevent Legionella bacteria outbreaks, as water testing logs did not include Legionella testing. Both the Maintenance Manager and Facility Administrator were unaware of the requirement for such testing, as mandated by CMS.
The facility failed to follow its Weight Assessment & Interventions policy for a resident with Alzheimer's disease by not reweighing the resident after a significant weight loss. The resident's weight dropped from 132 pounds to 125 pounds, exceeding the 5-pound threshold for a reweigh. Interviews with CNAs revealed inconsistencies in the reweighing process, and the DON confirmed the reweigh should have been done but was not documented.
The facility failed to ensure proper labeling and dosing of medications for a resident, leading to the potential for medication errors. The prescribed dose of SMZ/TMP was not unit dosed as required, and the blister pack was not re-labeled by the pharmacy, resulting in handwritten instructions being used instead.
Lack of Implemented End-of-Life Care Policy
Penalty
Summary
The deficiency involves the facility’s failure to have a developed and implemented policy and procedure for residents requiring end-of-life care. During a concurrent interview and record review with the Medical Records Manager, surveyors reviewed an undated document titled “Comfort Care and End-of-Life,” and the Medical Records Manager stated that the facility did not have an official policy and procedure in place, explaining that the comfort care policy had only been developed and had not yet been approved. In a separate interview, the Director of Nursing reported being unaware whether the facility had any policy on end-of-life care prior to the development of the Comfort Care and End-of-Life policy. As a result, the facility lacked an established, approved policy to guide staff in providing compassionate, dignified, and personalized care to residents at the end of life. No specific residents, diagnoses, or clinical conditions were identified in the report, and the deficiency is based on the absence of a formal, implemented end-of-life care policy as confirmed by facility leadership during interviews and document review.
Failure to Timely Report Alleged Physical Abuse
Penalty
Summary
The facility failed to report an allegation of physical abuse in a timely manner as required by its Abuse Policy and state law. A resident with severe cognitive impairment, including Alzheimer's disease and dementia, verbally reported being treated roughly during a shower. This allegation was discussed among staff and residents for several weeks before it was formally reported. The Activities Director (AD) heard the allegation during a Resident Council meeting but did not immediately report it to the Abuse Coordinator or Director of Nursing (DON). Additionally, a Certified Nursing Assistant (CNA) informed a Licensed Vocational Nurse (LVN) about the allegation, but the LVN did not report it at the time and could not recall when the incident occurred. The facility's policy requires that all abuse allegations be reported to the administrator and appropriate authorities within two hours if abuse or serious bodily injury is involved. However, the Report of Suspected Dependent/Elder Abuse (SOC-341) was not submitted to the California Department of Public Health (CDPH) until the day after the DON was informed, and weeks after the initial allegation was made. Interviews with staff confirmed that the abuse allegation was not reported in accordance with facility policy, resulting in a delayed notification to CDPH.
Widespread Sanitation Failures in Dietary Department
Penalty
Summary
Surveyors observed multiple failures in the facility's dietary department to maintain professional standards for food storage, preparation, and service under sanitary conditions. The stainless-steel prep area was found to have a painted wood ledge with dried food debris, fluid debris, hair, chipped paint, and exposed wood, making it unsanitary and difficult to clean. The large metal mixer had chipped paint, and the walk-in freezer exhibited significant ice build-up on various surfaces, which the Dietary Supervisor acknowledged as potential infection control issues. Additional unsanitary conditions included a coffee station with chipped laminate and wood, kitchenware with burnt-on food, and a center island and wood cabinets with chipped, worn paint and exposed wood, all confirmed by dietary staff as difficult to sanitize and potential sources of contamination. Further observations revealed structural and cleanliness deficiencies throughout the kitchen and storage areas. The ceiling above the stove was damaged and unpainted, the area above the laminate splash guard was discolored, and the kitchen and dishwashing room walls were grimy and had not been painted in years. The dry storage entryway and shelving had peeling paint and exposed wood, and the dry storage ceiling showed water damage. The dividing wall between the dishwashing area and kitchen had broken tiles, and the stainless-steel storage table and dishwashing room wall had rust, cracks, and exposed sheetrock, all of which were confirmed by staff as uncleanable and potential infection control issues. Interviews with the Dietary Supervisor, Dietary Manager, Maintenance Supervisor, and Infection Preventionist confirmed awareness of these unsanitary conditions and acknowledged their potential to harbor bacteria and create infection control problems. Facility documents reviewed indicated that all kitchenware and non-food contact surfaces should be cleaned after each use and kept in a sanitary condition, but these standards were not met in multiple areas of the dietary department.
Failure to Revise and Update Care Plans for Changes in Resident Condition
Penalty
Summary
The facility failed to ensure that care plans were developed and revised to reflect the current status of three residents. For one resident with dementia and severe cognitive impairment, a rash on the right ankle was documented in a Skin & Wound Evaluation but was not added to the resident's care plan. The Director of Nursing (DON) confirmed that the care plan was not updated to include this new condition. Another resident, admitted with a history of stroke, left-sided weakness, and a pressure ulcer, had documented skin damage to the tail bone in a Skin and Wound Evaluation, but the care plan did not reflect any skin breakdown. The DON also confirmed this omission during an interview. A third resident, who was bedbound with dementia and severe cognitive deficits, had a physician's order for comfort care, but no corresponding care plan was developed to address this order. The resident's daughter was identified as the responsible party for healthcare decisions. The DON confirmed that a care plan for comfort care was not created. These findings were based on interviews, record reviews, and a review of the facility's policy and procedure, which requires care plans to be reviewed and revised with any change in condition.
Failure to Submit PBJ Staffing Information
Penalty
Summary
The facility failed to submit the required Payroll Based Journaling (PBJ) staffing information to the Centers for Medicare and Medicaid Services (CMS). During a review on 04/18/24 at 10:10 AM, the Facility Administrator (FA) was unsure who was responsible for the submission, suggesting it might be the Director of Nursing (DON). The DON believed it was handled by payroll, while Human Resources (HR) stated it was not their responsibility. At 10:15 AM, the Accounting Clerk (AC) also confirmed they did not submit the PBJ data, thinking it was nursing's responsibility. No evidence was provided to show compliance with the PBJ data submission requirement.
Failure to Test Water for Legionella Bacteria
Penalty
Summary
The facility failed to have a program in place to prevent an outbreak of Legionella bacteria, which can cause Legionnaire's Disease, a potentially fatal lung infection. During an interview and record review, the Maintenance Manager (MM) provided water testing logs from a professional testing laboratory, which did not include testing for Legionella. The MM was unaware of the requirement to test for or prevent Legionella. The facility's water testing reports dated 2/5/24 and 2/2/24 indicated testing for coliform and E. coli but not for Legionella. Additionally, the County Water District report for 2022 did not include Legionella testing. The Facility Administrator (FA) also confirmed that she was unaware of the requirement for Legionella management and water testing as mandated by the Centers for Medicare and Medicaid Services (CMS).
Failure to Reweigh Resident After Significant Weight Loss
Penalty
Summary
The facility failed to follow its policy on Weight Assessment & Interventions for a resident diagnosed with Alzheimer's disease. Specifically, the facility did not reweigh the resident after a significant weight loss was recorded. The resident's weight dropped from 132 pounds on 2/2/2024 to 125 pounds on 3/3/2024, a loss of 7 pounds, which exceeded the 5-pound threshold that necessitates a reweigh the next day according to the facility's policy. The Director of Nursing (DON) confirmed that the weight should have been retaken, but it was not documented on the Vital Signs Grid. Certified Nursing Assistants (CNAs) responsible for weighing residents also confirmed that the reweigh should have been done but was not completed in this instance. Interviews with CNAs revealed inconsistencies in the reweighing process. CNA 3 stated that residents are weighed on Sundays and reweighed on Mondays if there is a weight change of 5 pounds or more. However, CNA 3 was unsure if the resident in question was reweighed on 3/3/2024. CNA 4 mentioned that weights are rechecked if they seem incorrect, but was unaware that the resident needed to be reweighed on the specified date. This failure to adhere to the policy created the potential for additional unaddressed weight loss and a detrimental clinical outcome for the resident.
Medication Labeling and Dosing Deficiency
Penalty
Summary
The facility failed to ensure that medications were labeled and administered according to professional pharmacy standards and physician orders. Specifically, a medication for Resident 10 did not match the current physician order and was not unit dosed as required by the facility's policy. The medication, Sulfametoxazole/trimethoprim (SMZ/TMP), was provided in a blister pack labeled with a higher dose than prescribed, requiring the nurse to split the tablet in half. This practice was not in accordance with the facility's policy, which mandates that medications be unit dosed to prevent under or overdosing. Additionally, the blister pack was not re-labeled by the pharmacy to reflect the new dose, and handwritten instructions were used instead, which is not an acceptable practice according to the Director of Nursing (DON) and the Pharmacy Consultant (PC). The PC emphasized that only pharmacy technicians or pharmacists are authorized to re-label medications and that red alert stickers should be used to note dosing changes. Resident 10, who was admitted to the facility in November 2019, was being treated for a urinary tract infection with the antibiotic SMZ/TMP. The physician's order specified a dose of 400 milligrams of sulfamethoxazole and 80 milligrams of trimethoprim. However, the blister pack contained tablets with double the prescribed dose, leading to the potential for medication errors. The DON confirmed that staff are not permitted to re-label medications and that the pharmacy must provide a properly labeled dose. The PC reiterated that the best practice is for the pharmacy to provide a pharmacy-printed label according to the current dose to avoid medication errors.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Cedarville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Modoc Medical Center D/p Snf | 19.5 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release June 2026) and official state health department websites.